ÿþ<html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns="http://www.w3.org/TR/REC-html40"> <head> <meta http-equiv=Content-Type content="text/html; charset=unicode"> <meta name=ProgId content=Word.Document> <meta name=Generator content="Microsoft Word 11"> <meta name=Originator content="Microsoft Word 11"> <link rel=File-List href="submit_files/filelist.xml"> <link rel=Edit-Time-Data href="submit_files/editdata.mso"> <!--[if !mso]> <style> v\:* {behavior:url(#default#VML);} o\:* {behavior:url(#default#VML);} w\:* {behavior:url(#default#VML);} .shape {behavior:url(#default#VML);} </style> <![endif]--> <title> Design Elements </title> <!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>Valleyins</o:Author> <o:LastAuthor>Paul</o:LastAuthor> <o:Revision>7</o:Revision> <o:TotalTime>135</o:TotalTime> <o:Created>2009-08-25T03:14:00Z</o:Created> <o:LastSaved>2009-08-25T03:58:00Z</o:LastSaved> <o:Pages>1</o:Pages> <o:Words>164</o:Words> <o:Characters>941</o:Characters> <o:Company>Valley Insurance</o:Company> <o:Lines>7</o:Lines> <o:Paragraphs>2</o:Paragraphs> <o:CharactersWithSpaces>1103</o:CharactersWithSpaces> <o:Version>11.8036</o:Version> </o:DocumentProperties> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:SpellingState>Clean</w:SpellingState> <w:GrammarState>Clean</w:GrammarState> <w:FormsDesign/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" LatentStyleCount="156"> </w:LatentStyles> </xml><![endif]--> <style> <!-- /* Font Definitions */ @font-face {font-family:Verdana; 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height:107.25pt'> <v:imagedata src="submit_files/image001.gif" o:title="logo"/> </v:shape><![endif]--><![if !vml]><img width=500 height=143 src="submit_files/image001.gif" v:shapes="_x0000_i1025"><![endif]></p> <form action="http://www.emailmeform.com/fid.php?formid=398533" method=post enctype="multipart/form-data"> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 style='mso-cellspacing:0in;background:white;mso-padding-alt:1.5pt 1.5pt 1.5pt 1.5pt'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes'> <td style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal align=center style='text-align:center'><o:p>&nbsp;</o:p></p> </td> </tr> </table> <p class=MsoNormal align=center style='text-align:center'><o:p>&nbsp;</o:p></p> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 style='mso-cellspacing:0in;margin-left:1.25in;background:white;mso-padding-alt: 1.5pt 1.5pt 1.5pt 1.5pt'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td nowrap valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><span style='font-size:10.0pt;color:black'>Your Name</span></p> </td> <td valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><INPUT TYPE="text" SIZE="45" NAME="FieldData0"></p> </td> </tr> <tr style='mso-yfti-irow:1'> <td nowrap valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><span style='font-size:10.0pt;color:black'>Your Email Address</span></p> </td> <td valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><INPUT TYPE="text" SIZE="45" NAME="FieldData1"></p> </td> </tr> <tr style='mso-yfti-irow:2'> <td nowrap valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><span style='font-size:10.0pt;color:black'>Phone number </span></p> </td> <td valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><INPUT TYPE="text" SIZE="15" NAME="FieldData2"></p> </td> </tr> <tr style='mso-yfti-irow:3'> <td nowrap valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><span style='font-size:10.0pt;color:black'>Zip Code</span></p> </td> <td valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><INPUT TYPE="text" SIZE="10" NAME="FieldData3"></p> </td> </tr> <tr style='mso-yfti-irow:4'> <td nowrap valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><span style='font-size:10.0pt;color:black'>Interests</span><o:p></o:p></p> </td> <td valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><INPUT TYPE="checkbox" NAME="FieldData4-0" VALUE="Design services" id=check40><span style='font-size:10.0pt;color:black'> <label for=check40> Design services </label> </span><br> <INPUT TYPE="checkbox" NAME="FieldData4-1" VALUE="Window coverings" id=check41><span style='font-size:10.0pt;color:black'> <label for=check41> Window coverings </label> </span><br> <INPUT TYPE="checkbox" NAME="FieldData4-2" VALUE="Furniture" id=check42><span style='font-size:10.0pt;color:black'> <label for=check42> Furniture </label> </span><br> <INPUT TYPE="checkbox" NAME="FieldData4-3" VALUE="Floor covering" id=check43><span style='font-size:10.0pt;color:black'> <label for=check43> Floor covering </label> </span><br> <INPUT TYPE="checkbox" NAME="FieldData4-4" VALUE="other" id=check44><span style='font-size:10.0pt;color:black'> <label for=check44> other </label> </span></p> </td> </tr> <tr style='mso-yfti-irow:5'> <td nowrap valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><span style='font-size:10.0pt;color:black'>Would you like us to call</span><o:p></o:p></p> </td> <td valign=top style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><INPUT TYPE="radio" NAME="FieldData5" VALUE="yes" id=radio50><span style='font-size:10.0pt;color:black'> <label for=radio50> yes </label> </span><br> <INPUT TYPE="radio" NAME="FieldData5" VALUE="no" id=radio51><span style='font-size:10.0pt;color:black'> <label for=radio51> no </label> </span></p> </td> </tr> <tr style='mso-yfti-irow:6'> <td colspan=2 style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="100%" style='width:100.0%;mso-cellspacing:0in;background:#FFCC99;mso-padding-alt: 3.75pt 3.75pt 3.75pt 3.75pt'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td colspan=2 style='padding:3.75pt 3.75pt 3.75pt 3.75pt'> <p class=MsoNormal><b><span style='font-size:10.0pt;font-family:Verdana; color:white'>Image Verification</span></b></p> </td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td width=10 style='width:7.5pt;padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><img width=161 height=51 id=captcha src="http://www.emailmeform.com/turing.php"></p> </td> <td valign=top style='padding:3.75pt 3.75pt 3.75pt 3.75pt'> <p class=MsoNormal><span style='color:black'>Please enter the text from the image</span> <br> <INPUT TYPE="text" MAXLENGTH="100" SIZE="10" NAME="Turing"><span class=GramE>[ </span><span style='mso-field-code:" HYPERLINK \0022\0022 "'><span class=MsoHyperlink>Refresh Image</span></span> ] [ <a href="http://www.emailmeform.com/?v=turing&amp;pt=popup">What's This?</a> ]</p> </td> </tr> </table> <p class=MsoNormal><o:p></o:p></p> </td> </tr> <tr style='mso-yfti-irow:7;height:2.5pt'> <td style='padding:1.5pt 1.5pt 1.5pt 1.5pt;height:2.5pt'> <div style='left:1600px;position:absolute;top:16px'> <p class=MsoNormal><span style='color:white'><a href="http://www.emailmeform.com"><span class=SpellE><span style='color:white'>php</span></span><span style='color:white'> form</span></a><o:p></o:p></span></p> </div> </td> <td style='padding:1.5pt 1.5pt 1.5pt 1.5pt;height:2.5pt'> <p class=MsoNormal><INPUT TYPE="text" MAXLENGTH="100" SIZE="3" NAME="hida2" style="display : none;"><INPUT TYPE="submit" ACTION="http://www.emailmeform.com/fid.php?formid=398533" VALUE="Send email" ENCTYPE="multipart/form-data" METHOD="post" NAME="Submit" ACTION="http://www.emailmeform.com/fid.php?formid=398533" ENCTYPE="multipart/form-data" METHOD=post><INPUT TYPE="reset" VALUE=" Clear " NAME="Clear"></p> </td> </tr> <tr style='mso-yfti-irow:8;mso-yfti-lastrow:yes'> <td colspan=2 style='padding:1.5pt 1.5pt 1.5pt 1.5pt'> <p class=MsoNormal><o:p>&nbsp;</o:p></p> </td> </tr> </table> </form> <p class=MsoNormal align=center style='text-align:center'><o:p>&nbsp;</o:p></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:8.0pt;font-family:Arial;display:none;mso-hide:all'><span style='mso-spacerun:yes'> </span></span><strong><span style='font-size:20.0pt'><o:p></o:p></span></strong></p> </div> </body> </html>